Retinal PHYSICIAN

Use the Power to Choose with VersaPACK

Surgeons discuss their experience with the vitrectomy surgical pack designed for flexibility and cost-effectiveness.

Peter K. Kaiser, MD (moderator): As vitreoretinal surgeons, we continually seek new ways to provide the best care for our patients in the most efficient and cost-effective manner. Efficiency and cost effectiveness are particularly important when we operate in our own ambulatory surgical centers (ASCs), where we can exercise the most control in choosing the tools we use. One new option we can consider is the VersaPACK from Synergetics USA, Inc. The idea behind VersaPACK is to allow surgeons to order posterior vitrectomy surgical packs with fewer limitations on what they contain while at the same time trying to reduce costs.

The VersaPACK is available in two main configurations. The standard configuration is designed to meet the needs of surgeons who are comfortable with their current pack configuration. The second, the efficiency configuration, provides the freedom to customize the pack to a surgeon’s preferences for infusion, illumination and trocar/cannula systems. Ancillary products are provided in individual sterile packs to eliminate waste associated with other bundled packs.

VersaPACK is designed to work with the market-leading Accurus Surgical System (Alcon) and is available in 20-gauge, 23-gauge and 25-gauge configurations. Some items are available in 27-gauge or and 29-gauge as well.

We have assembled a group of surgeons with considerable experience using the VersaPACK. I would like to hear what motivated you to try VersaPACK and what your experience has been thus far.

QUALITY PLUS COST SAVINGS

Drew Sommerville, MD: I perform approximately 90% of my cases in an ASC, and I use the Accurus system. I perform, on average, about eight to nine cases per week, typically operating on a few epiretinal membranes, macular holes, retinal detachments and diabetic cases each week. I’ve been using VersaPACK in our ASC for more than a year. I tried it because it offered cost effectiveness without sacrificing quality, and that’s exactly why I’ve continued to use it.

I’ve been using VersaPACK in our ASC for more than a year. I tried it because it offered cost effectiveness without sacrificing quality, and that’s exactly why I’ve continued to use it.

— Drew Sommerville, MD

One of the key features of the VersaPACK is that it gives me the ability to create a pack that reflects how I perform 90% of my cases.

Michael Davis, MD: I also operate in an ASC using the Accurus system, performing four or five cases per week. About 50% of my cases are macular, and about 50% are a mixture of retinal detachments and conditions related to diabetes. We’ve been using VersaPACK for about a year. We realized we weren’t using many of the items from the standard packs we had been buying from another company, so many items were going to waste.

We began using VersaPACK when we first started using an ASC. It actually helped us get into the ASC because we were able to tell them the cost would be less per pack than other options Synergetics also helped in the complete setup of our retina operating suite.

— Michael Davis, MD

With VersaPACK, we have a more streamlined, less cost-prohibitive pack, and the items in it are of the same — and in some respects better — quality as those in our previous packs.

Shann Lin, MD, FACS: I operate in an ASC. My case mix is approximately 50% macular and 50% retinal detachments, diabetes-related procedures and vein occlusions. I perform 10 to 15 cases per week and I’ve been using VersaPACK for almost a year.

John W. Kitchens, MD: I’ve used the VersaPACK since it was introduced. I’ve been with my current practice for 6 years, and up until this past year, we operated at the hospital using the Accurus Surgical System.

Last year, the hospital switched to the Constellation Vision System (Alcon). Not long after that, we had an opportunity to set up a retina OR in an ASC. The Accurus was the obvious choice for the ASC from a cost and ease-of-use aspect. Beyond that, we contacted Synergetics, and they equipped and set up the entire ASC OR for around $100,000, which was great.

Now I operate in the ASC two days per month, performing two to five cases per day. I use the hospital one day per week, and I know the price for the Constellation pack is more than double the VersaPack. The savings we achieved with VersaPACK really helped to make the possibility of moving cases to an ASC a reality.

ULTIMATE FLEXIBILITY IN PACK CONTENTS

Vitrectomy probes

Dr. Kaiser: The vitreous cutters available for inclusion in VersaPACK are made by Medical Instrument Development Laboratories, Inc. (MID Labs). What has been your experience with these MID Labs cutters?

Dr. Kitchens: The MID Labs cutters I’ve used are identical to the traditional Alcon cutter. The feel of the handpiece and the fluidics are no different.

Dr. Lin: For me, the MID Labs cutter and the Alcon cutter are very similar. One aspect of a cutter that is important to me is having a large enough port to achieve the posterior vitreous detachment adequately. Also, it needs to cut well. I can work very well at 2,500 cpm, and I can’t remember the last time I had a tear or other complication using a MID Labs cutter. The port is definitely large enough and also close to the tip, both help with inducing posterior vitreous detachment and core vitreous removal.

Dr. Davis: I like the fact that the MID Labs port is close to the tip, too. I often can use the cutter to peel membranes for which I would normally have needed forceps or scissors.

Dr. Sommerville: When I operate in the hospital setting, I use their Alcon 25-gauge cutter. I really can’t tell any difference between it and the MID Labs cutter in the Synergetics VersaPACK.

Dr. Kaiser: Do you find the stiffness of the 25-gauge MID Labs vitrectomy probe to be adequate?

Dr. Lin: The stiffness of the 25-gauge probe is excellent. I’ve been doing some 27-gauge surgeries as well.

Dr. Kaiser: The VersaPACK allows surgeons to use a 27-gauge cannula, light and cutter with the Accurus system, which isn’t currently possible with Alcon’s own packs. How do you like the 27-gauge surgery? Does your VersaPACK include everything you need? In what surgeries do you use this approach?

Dr. Lin: I’m still getting accustomed to the 27-gauge approach; therefore, I’m only performing straightforward cases. At this time, the 27-gauge VersaPACK doesn’t include all of the instruments we use in 23-gauge or 25-gauge procedures. However, I anticipate using 27-gauge more often in the future.

Dr. Kaiser: How efficient is the 27-gauge cutter?

Dr. Lin: For core vitreous removal, it’s slower than the 25-gauge cutter because the port can only be so big. However, I’m adapting to that, just as we all adapted to the difference between 20-gauge and 25-gauge instrumentation. It’s not too difficult to learn the best way to enter the eye and maneuver inside the eye when we switch to a different probe.

Dr. Sommerville: I prefer 25-gauge but occasionally I use 23-gauge. For example, when I combine a scleral buckle with vitrectomy, I suture the sclerotomies anyway, so I might as well have the power to move vitreous a little faster with 23-gauge.

Illumination

Dr. Kaiser: In what other ways do you customize your VersaPACKs?

Dr. Davis: I use the ultra-widefield light pipe in nearly every case, but it’s not a problem if I want to switch it out and use a chandelier.

Dr. Lin: I also like VersaPACK because I can choose a wide-angle illuminator, which I use with the Synergetics P-2 Photon mercury vapor light source. It increases the safety of my procedures because I can see the whole retina. It speeds up my cases compared with localized light, too, because I’m more assertive when I can see everything so well. Especially for complicated traction retinal detachments, I find the wide-angle light pipe to be indispensable. I’ve tried the Constellation Vision System, and in my opinion, the light pipe I include in my VersaPACK is superior even to the Constellation’s xenon light.

Dr. Sommerville: Another nice aspect of using the ultra-widefield light is being able to keep it back out of the vitreous, still have a great view of the entire retina and not worry about bumping the lens in phakic patients.

Dr. Kaiser: Do you use chandelier illumination when you are using the Photon?

Dr. Lin: I used to use chandeliers with the old halogen light source and the Accurus, and the light was very dim. The Photon can put out much more power for a chandelier. I still prefer the wide-angle light pipe, but the Photon with a chandelier is pretty good.

Dr. Sommerville: I don’t use chandelier lights often, but when I do, I use the 29-gauge Oshima Dual Chandelier from Synergetics. It inserts easily and produces good light for a 29-gauge instrument.

Cannula/trocar systems

Dr. Kaiser: Another interesting feature of VersaPACK is that the surgeon can decide what type of microincision cannula to use — polyamide or metal; valved or not valved.

Dr. Kitchens: Yes, and the One-Step trocar/cannula systems in the VersaPACK are very good. The trocar blade design makes a good incision. The funneled design of the metal cannula makes getting in and out easy. It’s a rare occasion that I have to swing out the viewing system to get my instruments into the eye.

Dr. Kaiser: The trocar developed by Synergetics has a flatter blade configuration compared to other systems. How does using this blade compare with what you were using in your old packs?

Another interesting feature of the VersaPACK is that the surgeon can decide what type of microincision cannula to use — polyamide or metal; valved or not valved.

— Peter Kaiser, MD

Dr. Lin: In my opinion, the Synergetics trocars are superior, especially for the way I create my incisions. I use a beveled incision, going in at a 45º angle before going straight down. In the past, when I used an Alcon 25-gauge entry system, sometimes with a reoperation I would see a tiny reverse “y” at the sclera. Now, sometimes with reoperations I can’t even find the old wound.

Dr. Davis: With the flatter blade of the Synergetics trocars, I use sutures much less frequently than I did when I was using my old packs.

Dr. Sommerville: I agree. The trocars for the VersaPACK allow good wound construction, and I haven’t had any leakage issues.

Dr. Kaiser: Do you use the polyamide cannulas or the metal cannulas?

Dr. Davis: I use the metal cannulas. I like that they’re funneled, and I find they don’t slip out.

Dr. Lin: I use mostly metal.

Dr. Sommerville: I’ve tried the polyamide cannulas, but they’re not funneled, so I find the metal cannulas a little more favorable because of that. The funneled metal cannulas certainly allow for easier insertion of instruments.

Dr. Kaiser: Have you used the valved cannulas for the VersaPACK?

None of us would put cost above quality, and I don’t think I’ve sacrificed any quality by using VersaPACK. That said, it’s astounding how much the ASC saves by using these packs.

— John Kitchens, MD

Dr. Sommerville: I typically don’t use valved cannulas, but I can see how they could be beneficial for reoperation situations where hypotony issues might be more likely.

Dr. Kaiser: Has anyone had issues with the valved cannulas in terms of getting instruments in and out?

Dr. Davis: I thought it might be difficult to open or enter the valved cannulas with soft-tipped instruments, but I didn’t notice any issues during the few times I’ve used them.

DIFFERENT PACKS FOR DIFFERENT PROCEDURES?

Dr. Kaiser: Do you order different VersaPACKs for different procedures, such as one for macula surgeries and another for traction detachments, or do you use use one type of pack for most of your cases?

Dr. Lin: I may have staff open certain things for some cases, but my basic pack stays the same.

Dr. Sommerville: We use just one pack configuration, but I like the idea of having a specific pack for a procedure, such as a traction detachment repair when I might want to use a chandelier instead of a light pipe for bimanual surgery.

Dr. Davis: We have a large, 12-person practice, so not only does this allow for different pack configurations for different procedures, but it also allows each physician to easily have different options.

TRANSITIONING TO IMPROVED EFFICIENCY

Dr. Kaiser: Let’s talk about incorporating VersaPACK into your ASCs.

Dr. Davis: For us, it was easy. We began using VersaPACK when we first started using an ASC. It actually helped us get into the ASC because we knew the cost would be less per pack than other options. Also, we were able to train the staff with VersaPACK because they hadn’t worked much in retina prior to our arrival. Synergetics also helped in the complete setup of our retina operating suite.

Dr. Sommerville: Transitioning to VersaPACK wasn’t an issue for our surgery center. At first, we had many individual items in smaller packs, which is part of the company’s effort to be versatile in providing what we want.

Dr. Kaiser: In your practices, are other surgeons using VersaPACK? If so, is everyone using the same configuration? In my practice setting, about half of the surgeons prefer 25-gauge and the other half prefer 23-gauge. Is VersaPACK flexible enough to address that in a cost effective manner?

Dr. Davis: We have six or seven surgeons in our group who use the same ASC. For the most part, we all use the same pack. However, if someone wanted a specific pack, or if someone wanted a light pipe all the time or a chandelier most of the time, that can be done. VersaPACK not only allows individual surgeons to have different packs for different types of cases, but it also allows the surgery center to offer different choices for different surgeons.

Dr. Lin: In our facility, the majority of us use the same pack.

Dr. Kaiser: Let’s talk about the service from Synergetics.

Dr. Lin: No problems. The company representative has been very responsive.

Dr. Sommerville: The service has been fantastic. I’ve had only a few packs with problems, and each time the company has sent replacements overnight or the representative has delivered them within a few days. They even replaced packs in cases where a scrub tech has accidentally dropped or broken something.

Dr. Kaiser: Are there any issues with using VersaPACK related to the warranty on the Accurus? Would Alcon perform that service on the Accurus?

Dr. Sommerville: It’s my understanding that Synergetics has people who will service the Accurus system. We haven’t had any issue like that, but it’s nice to know that Synergetics will take responsibility and come out and look at the machine if necessary. That seems to be an overall theme for the company, which underscores what we have said here. The representatives are very solid and attentive to our needs.

When we implemented the VersaPACK, our rep came around frequently to ensure our satisfaction and replace items as needed.

In my experience, the service has been a major advantage of using the Synergetics products.

Dr. Davis: I agree. The Synergetics sales force has been around for a long time; it’s a mature sales force with many solid product specialists. They’ve been around the Accurus for 11 years or so. Just by virtue of that, they have a great deal of inherent knowledge.

In addition, I know they have people who service the Accurus and will troubleshoot it from a third-party standpoint. We had a couple of issues with ours at startup, and they were attended to very quickly.

ALL THE POSITIVES WITH NO NEGATIVES

Dr. Kaiser: Many surgeons who are using the Accurus are evaluating the Constellation and/or the Stellaris PC (Bausch + Lomb), deciding if perhaps they should switch platforms since they offer distinct improvements over the Accurus. Can VersaPACK extend the life of the Accurus?

Dr. Kitchens: From an economic standpoint, it may make more sense to keep your Accurus and use VersaPACK instead of purchasing a whole new system, which involves quite a bit, including substantial start-up costs. You get a really high-quality cutter and pack, and you save money every time you open a VersaPACK compared with, for instance, an Alcon pack for the Constellation.

Dr. Lin: I tried the Constellation for a few weeks, and the 5,000-cpm cutter is nice. However, I can perform my cases very well with the Accurus, so I see no need to use the Constellation. That’s why I haven’t switched, and, as we’ve all said, performance-wise, the MID Labs cutters for the VersaPACK are similar or identical to the Alcon cutters.

Dr. Kitchens: I would definitely echo the previously made comments on the value of the VersaPACK. I know what our hospital pays for supplier’s packs, and it’s more than double what we pay at our ASC for the VersaPACK. The hospital is willing to do that, and I appreciate that. However, although I don’t have an investment in our ASC, the economics of what the owners choose to buy is certainly a crucial factor for them.

Dr. Sommerville: We may be able to save a minute or two per vitrectomy by upgrading to a surgical platform that has an ultra-high-speed cutting probe, but when I consider the significantly lower costs of keeping the Accurus and using VersaPACK, financially, this makes the most sense. These large savings on pack prices correspond directly to increasing our ASC’s net profit. Fortunately, the savings come without compromising product quality.

If we thought switching to a newer surgical platform or using other packs would lead to better results and other benefits for our patients, we would all make the switch no matter what the cost. However, with VersaPACK and the Accurus, we can deliver excellent results for a lower cost.

— Shann Lin, MD

Dr. Lin: If we thought switching to a newer surgical platform or using other packs would lead to better results and other benefits for our patients, we would all make the switch no matter what the cost. However, with VersaPACK and the Accurus, we can deliver excellent results for a lower cost.

Dr. Kitchens: Correct. None of us would put cost above quality, and I don’t think I’ve sacrificed any quality by using VersaPACK. That said, it’s astounding how much the ASC saves by using these packs.

Dr. Davis: We’ve touched on these points before, but they’re worth repeating. So many aspects of VersaPACK are significant advantages. For example, the blades on the trocars are fantastic. Also, I love having the ability to choose exactly what kind of light pipe I want and whatever other tools I want my surgical pack to contain. That flexibility without compromising quality is so important.

Dr. Kitchens: With VersaPACK, there’s no compromise in quality, which is the most important factor in making any purchase decision. It just so happens, however, that everything about using VersaPACK has worked out well for our practice. RP